Anxiety and OCD Flashcards
What are the physical symptoms of anxiety ?
- Sweating, hot flushes or cold chills
- Trembling or shaking
- Muscle tension or aches and pains
- Numbness or tingling sensations
- Feeling dizzy, unsteady, faint or lightheaded
- Dry mouth (not due to medication or dehydration)
- Feeling of choking
- A sensation of a lump in the throat, or difficulty in swallowing (Globus hystericus)
- Difficulty breathing
- Palpitations or pounding heart, or accelerated heart rate
- Chest pain or discomfort
- Nausea or abdominal distress (e.g. churning in stomach)
What are the cognitive symptoms of anxiety ?
- Fear of losing control, “going crazy or dying
- Feeling keyed up, on edge or mentally tense.
- Difficulty in concentrating, “mind going blank”
- Feeling that objects are unreal - derealization
- Feeling that the self is distant or “not really here” -depersonalisation
- Hypervigilance (internal and external)
- Racing thoughts
- Meta-worry (worry about everything, worrying about worrying)
- Health anxiety
- Beliefs about the importance of worry
- Preference for order and routine
What are the behavioural signs of anxiety ?
- Avoidance of certain situations
- Exaggerated response to minor surprises or being startled
- Difficulty in getting to sleep because of worrying
- Excessive use of alcohol/drugs (prescription or “recreational”)
- Restlessness and inability to relax
- Persistent irritability
- Seek reassurance from family/GP
- Checking behaviours e.g. compulsively checking switches, locks etc
What is the Amygdala?
It is the integrative center for emotions, emotional behavior, and motivation
Describe the physiology behind the normal stress response
Exposure to stress results in instantaneous and concurrent biological responses:
- To assess the danger
- To organise an appropriate response
Amygdala acts as the emotional filter of the brain for assessing whether sensory material via the thalamus requires a stress or fear response, if a stressor is judged to be stressful then the hypothalamus is activated
A series of responses to the stressor results in dose-dependent increase in catecholamines (adrenaline, noradrenaline and dopamine) and cortisol (released from the adrenal medulla)
Cortisol then acts as to mediate (& shut down) the stress response through negative feedback it acts on the pituitary, hypothalamus, hippocampus and amygdala - these sites are responsible for the stimulation of cortisol release
What are the different types of anxiety disorders ?
- Generalised Anxiety Disorder (GAD)
- Panic Disorder
- Agoraphobia
- Social Phobia
- Specific Phobia
- Obsessive Compulsive Disorder (OCD)
Describe what generalised anxiety disorder is
- Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is “free-floating”).
- The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Fears that the patient or a relative will shortly become ill or have an accident are often expressed.
What 3 things do you need to classify as GAD?
Needs to be severe enough to be:
- Long-lasting (most days for at least 6 months)
- Not controllable
- Causing significant distress / impairment in function
What problems is GAD associated with ?
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance (difficulty falling or staying asleep, restless unsatisfying sleep)
Who is more commonly affected by GAD and what is the typical disorder progression like ?
- Usually affects people 20-40
- 2:1 female to male ratio
- Chronic, fluctating course
- Associated with disability, medically unexplained physical symptoms, and overutilisation of health care services and resources.
90% of people with GAD are co-morbid with other psychiatric disorders, e.g. depression, substance abuse, other anxiety disorders
T or F?
True
What is the treatment of GAD?
- Cognitive Behavioural Therapy (CBT) and relaxation therapy
- Exercise
- meditation training
- Sleep hygiene
Drug options:
1st line = SSRI - usually sertraline, but also can be escitalopram, paroxetine
2nd line = try another SSRI or a SNRI - usually venlaflaxine
3rd line = pregabalin only used if not responsive to other treatments
If experiencing palpitations or tremor then put on a beta-blocker as this is effective in treating both the palpitations and the anxiety
Benzodiazepines only used as a short-term measure during crises otherwise don’t use
What is CBT ?
Psychological treatment to help the individual identify thoughts, assumptions, misinterpretations and behaviours that reinforce and perpetuate the anxiety
Describe panic disorder
- The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable.
- As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization). There is often also a secondary fear of dying, losing control, or going mad.
What other anxiety disorder may panic disorder be associated with ?
Agoraphobia, resulting in restricting what they do
How long do panic attacks in panic disorder usually last ?
30-45mins
What are many people with panic disorder co-morbid for?
Comorbid with other anxiety disorders, depression, drug & alcohol misuse
Describe the key point about the biology of panic attacks
There is increased metabolism anterior pole of temporal lobe – parahippocampal gyrus
What is the treatment of panic disorders ?
CBT should be offered
Pharmacological management:
- 1st line = SSRI - fluoxetine best
- 2nd line = tricyclics
Consider Benzodiazepines (short term only) like in GAD
What are the 3 main phobias ?
- Agoraphobia
- Social phobia
- Specific phobia
What is the characteristic features of a phobia ?
- Fear recognised as irrational
- Typified by avoidance and anticipatory anxiety
Describe agoraphobia
- A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes.
- Avoidance of the phobic situation is often prominent, and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations.
What does agorophobia often involve to avoid anxiety ?
- Others do shopping (for or with the patient)
- Drink alcohol to overcome fear
- Go shopping to 24 hour store at night (when quiet)
- Internet shopping!
Describe specific phobia (also called simple)
A marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation:
- For example: flying, heights, animals or insects, receiving an injection or seeing blood
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, akin to a panic attack
The person recognises that the fear is excessive or unreasonable
The phobic situation(s) is avoided or else endured with intense anxiety or distress
Normal functioning impaired by the avoidance, anxious anticipation, or distress in the feared situation(s)
What is the treatment of Agoraphobia and specific phobia ?
Behavioural Therapy – exposure:
- Graded exposure / systematic desensitisation
- Add in CBT if necessary
SSRIs / SNRIs if required
Describe social phobia/ social anxiety disorder
A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others - More than just being “shy”
The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.
Typically this occurs in relatively small social settings
Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound panic attack.
3 key anxiety symptoms are:
- blushing or shaking
- fear of vomiting
- urgency or fear of micturition or defaecation.
If you looked on brain imaging what would you see in someone experiencing social phobia ?
Increased bilateral activation of the amygdala and increased regional cerebral blood flow to the amygdala
What is social phobia strongly linked too ?
Alcoholism
What is the treatment of social phobia ?
- 1st line = offer CBT + graded exposure therapy
- Add 2nd line = SSRI
- 3rd line = another SSRI or a SNRI
Benzodiazepines (short term only) - beware of dependency issues as strong link with alcoholism
What is the difference between an obession and a compulsion ?
- Obession = unwanted and disturbing thoughts, images, or urges that are recognised as the patients own thoughts
- Compulsions are the repetitive physical behaviours and actions, or mental thought rituals, that are performed over and over again, in an attempt to relieve the anxiety caused by the obsessional thoughts.
Describe OCD
Recurrent obsessional thoughts and/or compulsive acts
Obsessional symptoms or compulsive acts must be present most days for at least 2 weeks AND be a source of distress and interference with activities
These symptoms are:
- Distressing,
- Time-consuming (1hr+ a day),
- Cause interference with social and occupational function, Excessive and unreasonable,
- Cause marked anxiety or distress
- Ego-dystonic - refrerring to the uncomfortable experience of such thoughts as imposed and intrusive
What are some of the common obessions someone may experience with OCD?
What are some of the common OCD compulsions that may be experienced by someone with OCD in response to their obessions ?
Who is most commonly affected by OCD?
Onset from, any age, including children and adolescents:
- Mean age of onset – 20
- Peak incidence for males – 13-15
- Peak incidence for females – 24-25
Runs in families but no gene identified
What is OCD commonly associated with ?
- 60-90% experience at least 1 major depressive episode
- Significant co-morbidity with schizophrenia, tourettes and other tic disorders, body dysmorphic disorder, eating disorders, trichtillomania
What is the treatment of OCD?
For mild functional impairment tx = low intensity CBT including exposure and response prevention (ERP)
For moderate function impairment tx = intensive CBT including ERP or SSRI (clompiramine may be used if SSRI contraindicated or person previously had a good response with it or prefers it)
For severe functional impairment tx = combo intensive CBT including ERP + SSRI (or clomipramine if SSRI contraindicated or person previously had a good response with it or prefers it)
What is the mechanism of action of benzodiazepines ?
Enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABAA receptor
What are the side effects/problems associated with benzodiazepine use ?
- Sedation and psychomotor impairment
- Discontinuation/withdrawal problems
- Dependency and abuse
- Alcohol interaction
- Can worsen co-morbid depression
What is PTSD and how is it treated ?
Characterised by a history of exposure to trauma (actual or threatened death, serious injury, or threats to the physical integrity of the self or others
Associated with:
- a response of intense fear, helplessness or horror (hence high rate of PTSD in rape victims). Intrusive symptoms (such as recollections, flashbacks or dreams)
- Avoidance symptoms (for example efforts to avoid activities or thoughts associated with the trauma)
- Negative alterations in cognitions and mood – Hyper-arousal symptoms.
Treat with EMDR (eye-movement desensitisation) and trauma focused- CBT + SSRIS
Go over this pic giving an overview of anxiety disorders
Treatment is generally with CBT or Behavioural Therapy and / or SSRIs
